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Adolescent Suicide
School Based Suicide Prevention Programs
Background
The goal of school based suicide prevention programs are to: increase awareness,
promote identification of students at high risk of suicide and suicide attempts,
provide information to students, teachers and parents on the availability of mental
health resources, and enhance the coping abilities of teenagers (Zenere and Lazarus, 1997).
In some states, such as California, school-based suicide prevention programs have
been mandated by law. These programs are aimed at sensitizing students and staff
to the risks of suicide and the "warning" signs of suicide in adolescents:
suicide threats or other statements about a desire to die, previous attempts, marked
changes in behavior, making arrangements to say goodbye. These programs include
both curricula components to teach students about these warning signs and what to
do, as well as non-curricula components such as peer groups, hot lines, intervention
services and parent training. Unfortunately, we could find no evaluations of these
interventions. There is also some suggestion that discussion of suicide with youth
can initiate imitative behavior and actually increase the risk of suicide.4
There is relatively little evaluation of school based programs which includes suicide
or suicide attempts as outcome measures. We decided not to include studies in which
the only outcome measure was change in students' knowledge, attitudes and beliefs
since there is no information on how well these correlate with actual risk of suicide.
We found five studies to review. None of the studies was a randomized controlled
trial. All studies were ecological.
Review of school based suicide prevention programs:
Author | Metha et al, 1998 |
Study design and target population | US population. Ecological design.
|
Intervention | State policies regarding school based
suicide prevention programs. |
Outcomes | Suicide rates between 1979-1994. |
Results | 19 states had adopted legislation
regarding youth suicide prevention. In 4 states, the laws specifically mandated
a school curriculum.
ANOVA revealed a decrease in suicide rates over the study
period but no relationship to any state program. |
Study quality and conclusions | National study but weak design.
Not clear what ages the data were on. |
Author | Zenere & Lazarus, 1997 |
Study design and target population | Dade County Public Schools.
Time series before-after design.. |
Intervention | Three tiered approach of prevention
intervention, and post-vention services in schools, started in 1989. |
Outcomes | Suicide attempts and completed suicides.
|
Results | Number of completed suicides dropped
by 63% from an average of 12.9 per year (1980-1988) to 4.6 per year (1989-1994)..
Suicide attempts decreased from 87 per 100,000 students (1989-1990)
to 31 per 100,000 (1993-1994). |
Study quality and conclusions | Before after study without a non-intervention
control group is a weak design.
Multifaceted program involving teachers, students, and parents. |
Author | MMWR, 1998 |
Study design and target population | Western Athabaskan American Indians
in New Mexico. |
Intervention | School based "natural helpers",
community education, crisis intervention, implemented in January 1990. |
Outcomes | Rates of suicidal acts: suicide attempts
and completions. |
Results | Rates of suicidal acts in 15-19 year
olds decreased from 59.8 per 1000 before (1988-1989) to 8.9 per 1000 in 1990-1991
and 10.9 in 1996-1997. This is an 82% reduction. |
Study quality and conclusions | Before after study without a non-intervention
control group is a weak design..
Multifaceted program involving teachers, students, and parents. |
Author | Wiegersma, et al, 1999 |
Study design and target population | Secondary schools in the Netherlands.
Design: mixed ecological. |
Intervention | Open consultation hours for adolescents
in school based clinics. |
Outcomes | Comparison of rates of suicide mortality
for 15-19 year olds; hospital admissions for suicide attempts among 15-19 year
olds in areas that had open consultation hours to those which did not. |
Results | Adjusted Odds Ratio for suicides in
areas with vs. without consultation was 0.98 (95% CI 0.69, 1.18).
Adjusted odds ratio for admission for suicide attempts was
1.30 (95% CI 0.97, 1.75). |
Study quality and conclusions | No effect of providing open consultation
hours for teens in schools on suicide attempts or completions. |
Author | Leisenring, 2000 |
Study design and target population | 15-18 year olds in 4 rural Vermont
counties.
Design is mixed ecological. |
Intervention | School/community based intervention.
Begun in March 1988. |
Outcomes | Suicide rates in 1982-1987 before
the intervention compared to 1988-1993 after the start of the intervention in
the 4 target counties compared to 4 control neighboring counties. |
Results | Suicide rates in the intervention
counties decreased by 73% compared to 41% in the control counties.
However, in a regression analysis, this was not significant. |
Study quality and conclusions | There was an effect although it was
not significant. There were only 4 counties however, and 8 suicides pre and
2 post. Thus, the power of the study was low. |
Author | Kalafat, 1997 |
Study design and target population | Mixed ecological design.
15-24 year olds in New Jersey. |
Intervention | School based Adolescent Suicide Awareness
Program first implemented in 1983-1984 in Bergen County, NJ.. |
Outcomes | Suicide rates for 15-24 year olds
in Bergen Co. compared to whole state. |
Results | Rates in Bergen County decreases by
40% between 1978-1982 and 1988-1992 compared to 9% decreases in NJ as |
Study quality and conclusions | Some evidence but not much information
about evaluation.. |
Summary of school based suicide prevention program studies
These studies show possible substantial effects of school based programs. The reductions
in injuries range from 40-80%. These are quite large. However, none of these were
RCTs and they all used weak study designs.
Recommendations
There is no evidence from these studies that school based suicide prevention programs
were harmful, i.e. no studies found an increased rate of suicide or attempts associated
with introduction of the program. However, the evidence for their effectiveness
is weak. We recommend that a large scale, rigorous randomized controlled trial of
these programs be conducted.
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